Successful RTW denotes successful work adjustment in the period consequent to cancer diagnosis and treatment (Barnard et al., 2016). The Theory of Work Adjustment (TWA) (Lofquist & Dawis, 1969) aligns with principles underlying the theoretical frameworks of person–environment fit (Dawis & Lofquist, 1984) or person–organisational fit (Bretz & Judge, 1994; Greguras & Diefendorff, 2009) and provides a relevant theoretical framework to understand the cancer employee’s RTW process. TWA originated from vocational rehabilitation research (Lofquist & Dawis, 1969) and evolved into a pro-active theoretical framework used to anticipate and cope with adjustment (Leonard & Schimmel, 2016). It has been singled out as one of the most robust and best validated theories in vocational psychology (Eggerth, 2008). Theories of person–environment (P–E) fit emphasise the need for correspondence between individual interests and abilities with the work environment, leading to appropriate career decisions and ultimately to job satisfaction and performance (Bretz & Judge, 1994). Extending the P–E fit approach, the TWA equally values the contribution of both the individual and the work environment in affecting job satisfaction and performance (Wang & Wanberg, 2017). The mutual fulfilment of the needs and expectations that the employee and the work context have of one another is expounded through the concepts of satisfaction and satisfactoriness (Eggerth, 2008). When the organisational system reinforces and fulfils the unique set of expectations and needs an individual brings to the work setting, satisfaction results. Satisfactoriness, on the contrary, results from the individual being capable to fulfil the requirements of the work (Leonard & Schimmel, 2016). Successful work adjustment thus results when there is a match between individual values and needs and the reinforcers offered by the work environment, and when there is similarly a match between the skills and abilities of the individual and what the work environment requires (Leonard & Schimmel, 2016).

Work adjustment is conceptualised as a continuous and dynamic process that spans several sequential stages in employees’ work life in an organisation, with each stage characterised by typical employee expectations of the work environment (Burlew, 2006). The process nature of RTW (Barnard et al., 2016) resonates with the concept of work adjustment as a process and begs an analysis of cancer survivors’ typical needs and expectations throughout the RTW process in order to facilitate an understanding of what the organisation can do to support RTW.

Various motivation theories align with TWA principles as they point to the importance of maximising fit between individual needs and expectations with the work environment to enhance work motivation, morale and productivity (Bretz & Judge, 1994; Eggerth & Flynn, 2012). TWA furthermore conceptualises job stress as a result of the mismatch between work demands and resources with the employee needs and expectations (Eggerth, 2008). Individual coping behaviour, according to Krohne (2002), aims to manage stress-relevant P–E transactions by focussing either on changing internal states to fit the environmental demands (emotion-focussed coping) or on changing environmental realities causing stress (problem-focussed coping). This original distinction between emotion-focussed versus problem-focussed coping types by Folkman and Lazarus (1980) has evolved into variable perspectives to conceptualising coping (Krohne, 2002; Rothmann, Jorgensen & Hill, 2011). What distinguishes emotion-focussed and problem-focussed coping from other strategies such as denial or avoidance is that the person addresses stress resulting from P–E mismatch whilst remaining in the situation physically, cognitively and emotionally. Similarly, through positive coping strategies such as meaning-making (Park, Edmonson, Fenster & Blank, 2008), the employee manages the stressful circumstance, whilst remaining in it. Meaning-making coping strategies relate to Lent’s (2004) model of restorative well-being which presents an integrative coping orientation to address resources internal to the person as well as external resources in the work environment, in order to attain adjustment. Coping strategies are usually regarded from the individual’s perspective, yet form an important foundation in the TWA to understand what is required from an organisational support perspective to facilitate work adjustment.

Understanding cancer survivors’ unique needs and expectations during the RTW process may therefore facilitate changes in the work environment to accommodate their needs and enhance their work motivation and morale. Application of TWA has moreover lead researchers to conclude that organisations should aid in the process of work adjustment by offering context-specific support (Wilson-Smith & Bates, 2014). Taking responsibility from an organisational perspective emphasises in this study the imperative role played by the organisation in guiding the successful RTW process. Beatty and Joffe (2006) emphasise employers’ responsibility to the needs of employees who have to cope with a chronic disease. Varekamp et al. (2009) suggested that the clarification of challenges, communication and problem-solving could help in managing successful work adjustment of the cancer employee. Organisational support improves the RTW experience and can reduce the possibility and extent of cancer-related work impairments during RTW (Van Muijen et al., 2013).

From the literature reviewed whilst executing and reporting on this study, it seems that cancer survivorship is predominantly studied in the health sciences and in the field of social work. Yet, understanding the RTW process of cancer employees is imperative in the context of industrial and organisational psychology (IOP). As a discipline, IOP concerns itself with facilitating employees’ work adjustment and optimal functioning in the work context. This article highlights a unique field of study in the discipline of IOP. In light of various researchers pointing out the continued need for research on the RTW process (Knott et al., 2014), this study contributes to the body of knowledge supporting cancer survivors’ successful work adjustment during RTW. Pragmatically, the study provides valuable guidance to employers in managing the cancer employees’ RTW process with the aim of optimising successful work adjustment during this time.

This study was performed at a private oncology unit and at a cancer support organisation set in the Southern Cape and Little Karoo regions of South Africa.

The clinical practice manager at the oncology unit and the medical sister at the cancer support institution acted as the gatekeepers to the study. Permission was obtained from management in both organisations to put up posters of the study in their reception areas, and permission was given to the gatekeepers to contact and inform cancer survivors of the study. Upon consent, the contact detail of interested participants was made available to the researchers of the study. At initial contact prior to interviews, the aim and nature of the study and relevant ethical issues such as protection of anonymity, confidentiality and the freedom to withdraw were explained to participants. These aspects were confirmed again during interviews at which time consent to digitally record interviews was also obtained. As confirmation of their understanding and consent to the study, all participants signed an informed participant consent form. Arrangements were also made with the gatekeepers for counselling referral should the need arise consequent to the interviews and participants were made aware of this opportunity.

Purposive sampling (Laher & Botha, 2012) was applied to incorporate participants with rich lived experience in the phenomenon under study (Laverty, 2003), namely RTW after cancer diagnosis and treatment. As such, sampling criteria required participants to have been diagnosed with cancer, having completed surgery and/or cancer treatment and having returned to the workplace. Eight cancer survivors participated in unstructured interviews (lasting between 45 and 60 min each). Participant demographics, occupational type, type of cancer and time period since diagnosis are summarised in Table 1. Code numbers (P1–P8) were assigned to protect participant confidentiality and preserve anonymity.

Congruent to hermeneutic phenomenological research, data were collected through unstructured interviews in order to elicit personal stories of lived experience pertaining to the research phenomenon (Crowther et al., 2017). The unstructured interview aided the researchers to focus interview discussions on the RTW process whilst remaining open to any specific participant insights regarding their work–life experiences as a cancer survivor. One open-ended question, ‘Please tell me about your experience when you returned to work after treatment’ was asked. To obtain a rich description of the participants’ experiences, follow-up probes were focussed on requesting participants to elaborate on thoughts and feelings regarding their RTW journey, the challenges they experienced during this time and the support they needed and received in and around the workplace.

Following the principles in Ricoeur’s framework of interpretation (see Svenningsen, Egerod & Dreyer, 2016; Tan et al., 2009), data were thematically analysed based on a fusion of meaning from the data with the researchers’ preconceived conceptual frameworks. Firstly, distanciation (see Dreyer & Pedersen, 2009) was obtained by separating the spoken discourse from the participants’ context and intention, through transcription of digitally recorded interviews. Appropriation (see Tan et al., 2009) was obtained through constant reflexive consultations within the research team on understanding their orientations and what they bring to the data when they attempt to interpret it. In moving iteratively between the content of the text and the researchers’ preconceived conceptual frameworks, data analysis operationalised what Heidegger (1967) referred to as the hermeneutic circle or Ricoeur’s concept of the hermeneutic arc (Tan et al., 2009). Stages of data analysis included (see Tan et al., 2009) an initial naive reading and descriptive explanation of what the text was saying about the RTW process; a thematic interpretation by integrating researchers’ theoretical preconceptions to add meaning to what the text was saying about the RTW process and by grouping related units of meaning; and developing in-depth understanding by moving back and forth between the initial explanation, the thematic interpretation and the researchers’ preconceived conceptual framework. Results from the thematic interpretation and the researchers’ in-depth understanding of how organisations can support the adjustment of cancer employees during RTW are reported here.

Findings are reported using a qualitative writing style depicting meaning by weaving researcher interpretations with rich, verbatim text from participants’ narratives.

Early in the RTW process, cancer employees project a strong need for emotion-focussed support resulting from them feeling misunderstood, overwhelmed and unsure when re-entering the work context. The unexpected physical and emotional challenges they now have to confront change what was normally a very familiar setting to them. Adjusting to the uncertainty and themselves being different in the same work setting challenges their sense of self and worth in the work context. Heightened emotions are evident, dominated by the fear that they will not be able to cope and do what is expected of them as before. In coping with their anxiety, participants speak of not being understood and supported, of feeling alone and afraid – evidenced in the translated verse of Participant six:

Another participant spoke freely of her struggles, but then suddenly denied any difficulties at work, immediately reverting back to her disappointment with not being supported at home. The emotional reaction seemed to portray both denial and projection of her needs to the work environment; she said:

Later Participant two however talks about feeling misunderstood in the work environment:

Similar to Participant two in the previous paragraph, Participant three feels that others do not understand her situation and she is not sure whether she will cope, feeling quite emotional:

The need for support is therefore further evidenced in how participants question themselves and their value. In reflecting such self-doubt, they present with feelings of uncertainty, isolation (misunderstood) and dejection. Lowered mood is reflected in the words of Participant four:

In expressing a need for their employers to provide them with more emotion-focussed support, participants thus wanted more sympathy and understanding and suggested that there should be more encouragement, opportunities for counselling and that the employer should provide more tangible support. Participant one suggested, for example, that employers should provide more encouragement:

Participant six also felt that employers should provide opportunities for counselling:

and continues to express a need for sympathy and understanding from her employer:

Cancer employees seem to be dependent on others in the work environment for affirmation that everything will be fine and that they are still of value to the employer and to co-workers.

When becoming more familiar with the new experience of the previously familiar work environment, cancer employees move towards acceptance of their new work–life situation. During this time, they seem to demonstrate a more rational approach to dealing with RTW and express a need for more information to understand what is happening to them and how they can more positively deal with the situation. Some participants specifically noted a need for the provision of relevant information at the workplace to assist both the employer and themselves in the RTW process as noted by Participant one:

Participant six, for example, ascribed her employer’s unrealistic expectations to a lack of knowledge:

Similarly, Participant two mentioned information as beneficial:

Focussing on how he utilised dietary information to help him manage his physical deterioration and consequently gain a more positive outlook on managing his health, Participant seven demonstrates the importance of knowledge:

During this stage, there is a conscious expression of needing knowledge and understanding to cognitively cope with previous uncertainties, lessening the anxiety that it created. As such Participant five attended a workshop enhancing her cancer-related health knowledge and she acknowledges:

Through knowledge participants want to confront their fears, feel more in control and experience more positive affectivity.

As a result of becoming more accepting of and positive towards their situation cancer employees re-appraise and rephrase their situation in more positive ways and consciously start to seek strategies and activities to help them address the work-related challenges they experience physically and socially. Their need in this stage relates to requiring problem-focussed support where participants were motivated to take action to address work environment realities to facilitate their adjustment. This need for practical guidance and directive support was evident in participants mentioning work-related strategies such as open communication, the setting of clear goals and feedback on their work performance. Participant two worked in an organisation where she felt free to express her needs and openly communicate mutual expectations:

and Participant six said:

Participants realistically acknowledge significant changes in their work performance such as relaxed attitude on task completion and deadlines (P4), limited physical capability because of fatigue, pain and physical discomfort (P1, P5 and P6) and reduced memory and concentration (P2, P3 and P7). Yet, they still want to pursue a career and find value in working:

Similarly Participant five had the expectation of a promotion in the following year. The furthering of her career met her expectation to be regarded as valuable, yet she needed guidance on expectations regarding her work performance and career prospects in the context of her dealing with cancer-related challenges at work. The issue of reverting to organisational policies and procedures to support coping is included here and reflected on in the story of Participant eight, demonstrating how her employer supported her through procedural activities and the availability of a special leave policy:

Active and conscious coping with the RTW process seem to grow self-confidence and participants express a need for purpose and meaning through work. They reflect on their personal growth and value as the pinnacle of their work adjustment during RTW, as reflected in the words of Participant five:

Such personal growth enables the cancer employee to have a meaningful impact on the lives of others in the work context. Here P1 (himself working with cancer patients) muses:

Similarly Participant two values her contribution to others as a result of her cancer experience:

It seems that participants move from questioning own value and purpose in initial RTW stages to appreciating life’s meaning and their purposeful self-worth in last phase. The critical illness makes them aware of their mortality and causes the cancer survivor to value time differently, wanting to spend it meaningfully. Some of the participants indicated that they feel they would like to spend more time with their family (‘…you know it is borrowed time we spent with each other’ [P7]), and others wanted to focus more on engaging in meaningful work, such as Participant two expressing the need to help others through their experience and volunteer work:

and:

At this stage, participants express needs that are more intrinsic in nature, calling for a work environment that empowers them to contribute purposefully to the work environment, colleagues and others in general. For the cancer employee, the need for self-actualisation derives from finding meaning, purpose and self-worth through the cancer and RTW experience. The organisation should provide the cancer employee with opportunities to fulfil such self-actualisation needs by involving them in meaningful work where they have an impact on others’ coping with work–life experiences. Examples of coping with RTW by finding meaning through spiritual or religious expression relate here. Participant seven expresses his acceptance of reality and how he copes with it through believing:

Initially, cancer employees that RTW present with negative emotions and lowered mood, requiring motivation to adjust and function optimally in the work environment. In this stage, the expectations regarding organisational support focus on the emotional needs of the cancer survivor to feel understood, supported and valued. Motivation is defined by Latham and Pinder (2005, p.486) as ‘a psychological process resulting from the interaction between the individual and the environment’ and fundamentally includes addressing affective–cognitive drivers of behaviour. To address the need for understanding, organisations should provide emotional support through counselling but also tangible support in the form of more time off, to demonstrate understanding of the cancer employee’s challenges. Motivation can be attained through flexible management practices and work arrangements, allowing the cancer employee to dictate what they are capable of and when, keeping them occupied, considering flexitime or working from home, revising leave benefits, creating transitional work, looking at work site accommodation and providing counselling services through an employee assistance programme (EAP). Tangible support demonstrates understanding and establishes the organisation’s investment to facilitate the adjustment process for the cancer employee to regain direction and self-confidence at work.

The participants already had reasonable knowledge about their illness and the prognosis, yet they voiced the need for continued information. According to Varekamp et al. (2009), the organisation can empower cancer survivors by increasing their knowledge and skills, thus enabling them to take responsibility for finding solutions to challenges in the workplace. Participants also emphasised the importance of information for their employers and co-workers to facilitate understanding and decision-making relevant to the cancer employee’s work adjustment. Previous studies also indicate that line managers and colleagues should be equipped with information regarding the cancer survivor’s work ability to be able to give the necessary support (Popa, 2015; Yarker et al., 2010). The participants experience knowledge about the disease as an important requirement for both employers and co-workers in the RTW process. Similarly, Popa (2015) notes that proper information will lead to awareness and will generate pro-active behaviour and supportive attitudes in the work environment.

Navigation is aimed at providing cancer employees with practical guidance in the work environment through open communication of mutual performance expectations, revised career goals, performance feedback, skills training and availability of relevant organisational policies and procedures. Navigation as a management approach directs a joint employer–employee responsibility where cancer employees feel safe to communicate their limitations and needs and the employer communicates performance expectations and reasonable work accommodations. By setting clear goals and giving regular feedback, the cancer employee can make suggestions and adjustments to improve work outcomes.

In response, the organisation should allow alternative work accommodation and provide practical benefit strategies by revising leave benefits and work hours and creating transitional work (Mitchell & Bruen, 2008). In this regard, Ross (2007) introduced vocational rehabilitation as an important approach to assist the cancer employees’ adjustment during RTW. Vocational rehabilitation includes a wide range of interventions such as an assessment of cancer employees’ needs, re-training, RTW management by employers and reasonable adjustments in work structure and design (Ross, 2007). Clark and Stovall (1996) add hereto interventions that focus on building skills and coping strategies. An organisational policy framework and a RTW programme assisting cancer employees with tangible guidance regarding resources and procedures available to ease their adjustment seem essential. Apart from clarifying available resources and support and how to access these, a policy guides management to ensure that cancer employees are managed in a consistently fair manner (Nowrouzi et al., 2009). The RTW policy should delineate relevant RTW adjustment information (Popa, 2015), emotional support and resources available, a tailored performance management procedure and allowance of alternative work accommodation or job restructuring.

In reaching the final stages of adjustment, cancer employees rely on meaning-making through spiritual understanding, spending time meaningfully and giving to others, to cope with their situation. During this stage, the cancer survivor begins to balance himself or herself somewhere between the old and new self, integrating a stable and adjusted self. The opportunity to express beliefs, religion, spirituality and volunteering should be provided, and adjustment interventions should focus on psychological and spiritual well-being. For cancer survivors, meaningfulness goes beyond the workplace and is more about finding a connection to humanity through their jobs (Bailey & Madden, 2016). Organisations can encourage this by creating a culture of ethics, morals and corporate social responsibility that brings an employee’s personal values and work life together (Bailey & Madden, 2016). Workplace stability can be achieved by facilitating positive change processes and also by providing a meaningful or purposeful career as a whole.

Ultimately, as the cancer survivor moves through the hierarchical needs stages in the RTW process, it is necessary to provide an integrative RTW management approach to stabilise their experience of having their hierarchy of needs addressed. Addressing their needs from an integrative perspective will enable them to self-actualise as a cancer survivor with a meaningful or purposeful career. Hryniuk and Waechter (2011) suggest that a comprehensive cancer assistance programme will enable employers to navigate cancer employees through the RTW process to ensure successful work adjustment.